This invention relates to surgical methods and apparatus in general, and more particularly to methods and apparatus for fixing bone blocks in bone tunnels.
The complete or partial detachment of ligaments, tendons and/or other soft tissues from their associated bones within the body are relatively commonplace injuries. Tissue detachment may occur as the result of an accident such as a fall, overexertion during a work-related activity, during the course of an athletic event, or in any one of many other situations and/or activities. Such injuries are generally the result of excess stress being placed on the tissues.
In the case of a partial detachment, commonly referred to under the general term xe2x80x9csprainxe2x80x9d, the injury frequently heals itself, if given sufficient time, and if care is taken not to expose the injury to undue stress during the healing process. If, however, the ligament or tendon is completely detached from its associated bone or bones, or if it is severed as the result of a traumatic injury, partial or permanent disability may result. Fortunately, a number of surgical procedures exist for re-attaching such detached tissues and/or completely replacing severely damaged tissues.
One such procedure involves the re-attachment of the detached tissue using xe2x80x9ctraditionalxe2x80x9d attachment devices such as staples, sutures and/or cancellous bone screws. Such traditional attachment devices have also been used to attach tendon or ligament grafts (often formed from autogenous tissue harvested from elsewhere in the body) to the desired bone or bones.
Another procedure is described in U.S. Pat. No. 4,950,270, issued Aug. 21, 1990 to Jerald A. Bowman et al. In this procedure, the damaged anterior cruciate ligament (xe2x80x9cACLxe2x80x9d) in a human knee, for example, is replaced by first forming bone tunnels through the tibia and femur at the points of normal attachment of the anterior cruciate ligament. Next, a ligament graft with a bone block on one of its ends is sized so as to fit within the bone tunnels. Suture is then attached to the bone block and thereafter passed through the tibial and femoral bone tunnels. The bone block is then drawn through the tibial tunnel and up into the femoral tunnel using the suture. As this is done, the graft ligament extends back out of the femoral tunnel, across the interior of the knee joint, and then through the tibial tunnel. The free end of the graft ligament resides outside the tibia, at the anterior side of the tibia. Next, a bone screw is inserted between the bone block and the wall of femoral bone tunnel so as to securely lock the bone block in position by a tight interference fit. Finally, the free end of the graft ligament is securely attached to the tibia.
In U.S. Pat. No. 5,147,362, issued Sep. 15, 1992 to E. Marlowe Goble, there is disclosed a procedure wherein aligned femoral and tibial tunnels are formed in a human knee. A bone block with a graft ligament attached thereto is passed through the tunnels to a blind end of the femoral tunnel where the block is fixed in place by an anchor. The ligament extends out the tibial tunnel, and the end thereof is attached to the tibial cortex by staples or the like. Alternatively, the end of the ligament may be fixed in the tibial tunnel by an anchor or by an interference screw.
Various types of ligament and/or suture anchors, and anchors for attaching other objects to bone, are also well known in the art. A number of these devices are described in detail in U.S. Pat. Nos. 4,898,156; 4,899,743; 4,968,315; 5,356,413; and 5,372,599, each of which is presently owned by Mitek Surgical Products, Inc. of Westwood, Mass., the assignee of this patent application.
One known method for anchoring bone blocks in bone tunnels is through xe2x80x9ccross-pinningxe2x80x9d, in which a pin, screw or rod is driven into the bone transversely to the bone tunnel so as to intersect the bone block and thereby cross-pin the bone block in the bone tunnel. In order to provide for proper cross-pinning of the bone block in the bone tunnel, a drill guide is generally used. The drill guide serves to ensure that the transverse passage is positioned in the bone so that it will intersect the appropriate tunnel section and the bone block. Drill guides for use in effecting such transverse drilling are shown in U.S. Pat. Nos. 4,901,711; 4,985,032; 5,152,764; 5,350,380; and 5,431,651.
Other patents in which cross-pinning is discussed include U.S. Pat. Nos. 3,973,277; 5,004,474; 5,067,962; 5,266,075; 5,356,435; 5,376,119; 5,393,302; and 5,397,356.
In U.S. Pat. No. 5,431,651, issued Jul. 11, 1995 to E. Marlowe Goble, it is said that a cross-pin screw may be formed out of a material which may be absorbed by the body over time, thereby eliminating any need for the cross-pin screw to be removed in a subsequent surgical procedure.
However, such absorbable cross-pin screws as are presently known in the art lack sufficient strength to be passed directly into the bone and the bone block. Accordingly, to use absorbable cross-pin screws, one must first drill a hard metal drilling implement into the bone and bone block, remove the drilling implement, and then replace the drilling implement with the absorbable cross-pin screw. However, removal of the hard metal drilling implement often permits the bone block to shift in the tunnel, such that the subsequent insertion of the absorbable cross-pin screw becomes impossible.
Accordingly, there exists a need for a method and apparatus for fixing a bone block in a bone tunnel such that upon completion of the procedure, the bone block is cross-pinned in the bone tunnel by elements which are made of absorbable material.
The object of the present invention is, therefore, to provide a method for fixing a bone block in a bone tunnel such that the bone block is retained in the tunnel by cross-pins which are made of a material which is absorbable by the body.
A further object of the present invention is to provide devices by which the aforementioned method may be realized.
These and other objects of the present invention are addressed by the provision and use of a novel method and apparatus for fixing a bone block in a bone tunnel.
In one form of the invention, the novel method comprises the steps of placing the bone block in the bone tunnel, and then advancing spaced-apart first and second drill means through the bone transversely of the bone tunnel so as to intersect the bone block and extend therethrough. The method further includes the steps of removing one of the drill means and replacing the one removed drill means with a first absorbable rod, and then removing the other of the drill means and replacing the other removed drill means with a second absorbable rod, whereby the bone block will be retained in the bone tunnel with the absorbable rods. In one form of the invention, the first and second drill means may comprise metal wires.
The objects of the present invention are further addressed by the provision and use of an alternative method for fixing a bone block in a bone tunnel. The method comprises the steps of placing the bone block in the bone tunnel, and then advancing spaced-apart first and second trocar and sleeve assemblies through the bone, transversely of the bone tunnel, so as to intersect the bone block and extend therethrough, the trocar in each of the assemblies being disposed within one of the sleeves of the assemblies and substantially filling the sleeve. The method further includes the steps of removing the trocar from the first of the sleeves, advancing a first absorbable rod through the first sleeve and through the bone block, and then removing the first sleeve, so as to leave the first absorbable rod in the bone and the bone block. The method further includes the steps of removing the trocar from the second of the sleeves, advancing a second absorbable rod through the second sleeve and through the bone block, and then removing the second sleeve, so as to leave the second absorbable rod in the bone and the bone block, whereby the bone block will be retained in the bone tunnel with the absorbable rods.
The objects of the present invention are further addressed by the provision and use of another alternative method for fixing a bone block in a bone tunnel. The method comprises the steps of placing the bone block in the bone tunnel, and then advancing spaced-apart first and second trocar and sleeve assemblies through the bone transversely of the bone tunnel so as to intersect the bone block and extend therethrough, the trocar in each of the assemblies being disposed within one of the sleeves of the assemblies and substantially filling the sleeve. The method further includes the steps of removing the trocar from the sleeves, advancing absorbable rods through the sleeves and through the bone block, and then removing the sleeves from the bone block and the bone, so as to leave the absorbable rods in the bone block and the bone, whereby the bone block will be retained in the bone tunnel with the absorbable rods.
In accordance with a further feature of the present invention, there is provided a rack assembly for cross-pinning a bone block in a bone tunnel in a human femur, the rack assembly comprising an L-shaped member having a base portion and an arm portion extending transversely of the base portion, and a cannulated sleeve for movement through a tibia and into the femur and for disposition in the femoral bone tunnel, the cannulated sleeve having an enlarged head portion at a free end thereof for disposition in the bone tunnel in the femur and being connectable to the base portion of the L-shaped member at an opposite end thereof. The rack assembly further includes a trocar sleeve guide member removably connectable to the arm portion of the L-shaped member and having bores extending therethrough at an angle normal to a longitudinal axis of the cannulated sleeve""s head portion, first and second trocar sleeves for movable disposition in the bores, respectively, and at least one trocar for disposition in the trocar sleeves, the trocar being interconnectable with the trocar sleeve in which the trocar is disposed such that the trocar sleeve and the trocar therein are movable axially toward the cannulated sleeve""s head portion and rotatable together, such that the interconnected trocar and trocar sleeve are adapted for drilling into the femur and the bone block. The trocar is removable from the trocar sleeves, and absorbable rods are provided for sliding through the trocar sleeves and through the bone block, the trocar sleeves being removable from the bone block and the femur and from the absorbable rods, so as to leave the absorbable rods in the bone block and the femur.
In accordance with a still further feature of the present invention, there is provided another rack assembly for cross-pinning a bone block in a bone tunnel in a human femur. The rack assembly comprises an L-shaped member having a base portion and an arm portion extending transversely of the base portion, and a cannulated sleeve for movement through the femur until a free end thereof is disposed adjacent to the bone block, with an opposite end thereof being connectable to the base portion of the L-shaped member. A trocar sleeve guide member is removably connectable to the arm portion of the L-shaped member and is provided with bores extending therethrough at an angle normal to a hypothetical extension of a longitudinal axis of the cannulated sleeve. First and second trocar sleeves are provided for movable disposition in the bores, respectively. At least one trocar is provided for disposition in the trocar sleeves, the trocar being interconnectable with the trocar sleeve in which the trocar is disposed such that the trocar sleeve and the trocar therein are movable axially toward the bone block and rotatable together, such that the interconnected trocar and trocar sleeve are adapted for drilling into the femur and the bone block. The trocar is removable from the trocar sleeves, and absorbable rods are slidable through the trocar sleeves and through the bone block, the trocar sleeves being removable from the bone block and the femur and from the absorbable rods so as to leave the absorbable rods in the bone block and the femur.
In accordance with a further feature of the invention, there is provided a method for fixing a bone block in a bone tunnel in a bone, the method comprising the steps of:
forming a bone tunnel in the bone, the bone tunnel comprising an open end, a portion adjacent the open end having a transverse diameter sized to receive the bone block and an at least partially closed end located internally of the bone;
locating the bone block in the bone tunnel such that one end thereof is disposed substantially adjacent to the at least partially closed end of the bone tunnel;
advancing a drill means through the bone transversely of the bone tunnel such that the drill means intersects and extends through the bone tunnel and back into the bone substantially adjacent the other end of the bone block; and
removing the drill means from the bone and replacing the drill means with a rod;
whereby to retain the bone block in the bone tunnel between the at least partially closed end and the rod.
In accordance with a further feature of the invention, there is provided a method for deploying an element in bone, the method comprising the steps of:
providing a trocar and trocar sleeve combination comprising a hollow sleeve having a distal end, a proximal end and a longitudinal length, wherein the interior of the sleeve defines a substantially cylindrical longitudinal passageway between the proximal end and the distal end, and a pair of opposing grooves in the sidewall of the passageway, the grooves extending respectively from the proximal end of the sleeve to opposing closed ends spaced from the distal end of the sleeve; and
a trocar including a shaft having a transverse cross-section adapted to be slidingly received in the passageway, a pointed distal end adapted for drilling into bone and a pair of opposing projections adapted to be slidingly received in the grooves when the shaft is located in the passageway such that the extension of the pointed end out of the distal end is limited according to the longitudinal distance between the pointed end and the projections in relation to the longitudinal spacing of the closed groove ends from the distal end of the shaft;
whereby when the trocar is inserted into the passageway, the resulting trocar and trocar sleeve combination may be rotated and drilled distally into bone as a unit and the trocar may be slidably, proximally removed from the sleeve;
drilling the trocar and trocar sleeve combination into the bone;
removing the trocar from the trocar sleeve;
inserting the element into the bone through the passageway of the sleeve; and
removing the sleeve from the element and the bone.
In accordance with a further feature of the invention, there is provided a method for fixing a portion of a piece of tissue in a bone tunnel, the method comprising:
advancing a trocar and trocar sleeve combination into a bone transversely to a bone tunnel formed therein such that the trocar and trocar sleeve combination extends through the bone and across the bone tunnel;
removing the trocar from the trocar sleeve;
inserting an absorbable rod into the bone through the sleeve and removing the sleeve so as to leave the absorbable rod extending across the bone tunnel;
attaching one end of a length of cord-like material to the piece of tissue adjacent the portion thereof which is to be located in the bone tunnel;
threading the other end of the length of cord-like material into an open end of the bone tunnel, around the absorbable pin extending across the bone tunnel, and back out of the open end of the bone tunnel; and
pulling on the other end of the cord-like material so as to draw the portion of the piece of tissue into the open end of the bone tunnel, around the absorbable pin extending across the bone tunnel, and back out of the open end of the bone tunnel,
whereby the portion of the piece of tissue is looped over the absorbable pin within the bone tunnel for fixation therein by securement of the portions of the piece of tissue extending out of the open end of the bone tunnel.
In accordance with a further feature of the invention, there is provided a method for fixing a bone block in a bone tunnel in a bone, the method comprising the steps of:
placing a solid bone block in the bone tunnel;
advancing at least one trocar and trocar sleeve assembly into the bone transversely of the bone tunnel such that the distal end of the at least one trocar and trocar sleeve assembly resides in the bone proximate the sidewall of the bone tunnel, the trocar in the at least one assembly being disposed within and substantially filling its associated trocar sleeve;
removing the trocar from the at least one trocar and trocar sleeve assembly and inserting a rod into the at least one sleeve;
slidably inserting one end of an elongate shaft into the sleeve so as to abut the rod;
tapping the other end of the elongate shaft so as to drive the rod out of the sleeve, through the bone and into the bone block.
In accordance with a further feature of the invention, there is provided a method of maintaining reduced fractures in bone in position for healing, the method comprising the steps of:
advancing at least one trocar and trocar sleeve assembly though the bone on one side of a reduced fracture, across the reduced fracture and into the bone on the other side of the reduced fracture, the trocar in each of the at least one trocar and trocar sleeve assembly substantially filling its associated sleeve;
removing the trocar from the at least one trocar and trocar sleeve assemblies;
inserting a rod through the at least one sleeve and into the bone on the other side of the reduced fracture; and
removing the at least one sleeve from the bone and the rod so as to leave the rod in the bone extending across the reduced fracture.
In accordance with a further feature of the invention, there is provided a method for delivering materials into the interior of bones, the method comprising the steps of:
advancing at least one trocar and trocar sleeve assembly into the interior of a bone, the trocar in the at least one trocar and trocar sleeve assembly substantially filling its associated sleeve;
removing the trocar from the at least one trocar and trocar sleeve assembly;
delivering the materials to the interior of the bone through the at least one sleeve; and
removing the at least one sleeve from the bone.
In accordance with a further feature of the invention, there is provided a method for fixing a bone block in a bone tunnel, the method comprising the steps of:
providing a rack assembly including an L-shaped member having a base portion and an arm portion extending transversely of the base portion, a cannulated sleeve at one end thereof releasably connectable to the base portion of the L-shaped member and, at the other end thereof, adapted for disposition in the bone tunnel to align the rack assembly relative to the intended fixation location of the bone block, a trocar sleeve guide member removably connectable to the arm portion of the L-shaped member such that bores extending therethrough are disposed at an angle transverse to the intended fixation location of the bone block in the bone tunnel, first and second trocar sleeves for movable disposition in the bores, respectively, at least one trocar for movable disposition in the trocar sleeves, the at least one trocar being interconnectable with the trocar sleeve in which it is disposed, each the trocar sleeve, when the at least one trocar is located therein, being movable axially toward the intended fixation location of the bone block and rotatable together with the trocar such that the interconnected trocar and trocar sleeve are adapted for drilling into the bone, the at least one trocar being respectively removable from the trocar sleeves, and rods for sliding into the trocar sleeves;
with the cannulated sleeve in its aligning position in the bone tunnel and the sleeve guide member connected to the arm, advancing the trocar and trocar sleeve assemblies into the bone but not into the bone tunnel;
removing the at least one trocar from the trocar and trocar sleeve assemblies;
removing the cannulated sleeve from the bone tunnel and the first and second sleeves from the sleeve guide;
locating a bone block in the bone tunnel in alignment with axial projections of the first and second sleeves disposed in the bone;
providing a first elongate trocar and advancing the first trocar through the first sleeves, through the bone located between the distal ends of the first sleeves and the bone tunnel, and into the bone block;
providing a second elongate trocar and advancing the second trocar though the second sleeve, through the bone between the distal end of the second sleeve and the bone tunnel, and into the bone block;
removing the second elongate trocar from the bone block, the bone and the second sleeve;
inserting a rigid rod through the second sleeve and into the bone and the bone block;
removing the first elongate trocar from the bone block, the bone and the first sleeve;
inserting another rigid rod though the first sleeve into the bone and the bone block; and
removing the first and second sleeves from the bone.
In accordance with a further feature of the invention, there is provided a trocar and trocar sleeve assembly for use in forming passageways in bone, the assembly comprising:
a trocar comprising a shaft, a distal drilling tip and at least one projection extending radially of the shaft at a pre-selected longitudinal distance proximally of the distal tip; and
a trocar sleeve having a distal end and a proximal end defining a longitudinal bore extending between the distal end and the proximal end, and at least one longitudinal groove in the sidewall of the bore extending from the proximal end of the sleeve to a closed distal end located a pre-selected longitudinal distance proximally of the distal end of the sleeve;
the trocar being adapted to slidingly engage the bore of the sleeve with the at least one radial projection slidingly engaging the at least one longitudinal groove, and the pre-selected longitudinal distance being such that when the at least one radial projection engages the closed end of the at least one longitudinal groove, the distal drilling tip of the trocar projects distally of the distal end of the sleeve,
whereby the trocar and the trocar sleeve may be releasably interconnected with one another for integral rotational and distally directed longitudinal movement.
In accordance with a further feature of the invention, there is provided a surgical kit for locating objects or materials in bone, the kit comprising:
at least two trocar sleeves, at least one trocar adapted for releasable interconnection with the sleeves for integral rotational and distal longitudinal movement therewith, at least one elongated, stepped trocar adapted for slidable and rotational movement through the sleeves and into bone, a rack assembly adapted for controlling the angle at which the sleeves and trocars penetrate the bone so as to provide passageways into which the objects and/or materials may be inserted, and plunger and tapping means adapted to pass the objects and/or materials into the bone via passageways formed therein by the sleeves and trocars.